Directed Neurological Examination

The first goal of the neurological examination of memory is to ascertain that memory impairment is not secondary either to a specific perceptual, motor, or cognitive disability or to a broad impairment of mental status. This goal can be accomplished by performing a mental status assessment and brief bedside tests of orientation, receptive and expressive language, and visual constructional abilities. Confusional states can be evaluated both informally, while the patient tells his or her history, by noting confusion or incoherence in thinking, anxiety level, and inconsistencies and inaccuracies about dates and symptoms, and formally by asking about the present day, date, place, and year. Further memory assessment should be undertaken only if a patient's level and content of consciousness and attention are determined to be unimpaired. One widely used standardized mental status test is the mini mental status examination (MMSE). '31!

The second goal of the directed neurological examination is to characterize the nature of a primary memory problem by the use of brief tests of immediate, long-term, and remote memory. Tests of immediate memory require the patient to repeat exactly a series of random digits; normal adults can repeat 5 to 7 digits. Such tests assess the ability to attend to events adequately and to encode information. Immediate memory is relatively spared in patients with even the most severe amnesias and moderate dementias. Failure to immediately repeat 5 digits in the order presented suggests a problem in attention or orientation. The rare exceptions include patients with specific immediate memory deficits who may be differentiated from inattentive patients by virtue of their intact immediate memory in another modality (e.g., when shown 5 digits visually).

Tests of long-term memory (often referred to as short-term memory in standard neurological usage) require the patient to remember and later recall (e.g., after 3 minutes) three items of information (e.g., words or objects). It is useful to warn the patient that memory will be tested for the information and to have the patient immediately repeat the words or name the objects to rule out attentional, perceptual, and linguistic bases for any later memory failure. It is important that the delay between the study and the test be filled with activity such as counting before the patient is asked to recall the words or objects. Otherwise, a patient may quietly rehearse the words, and the test no longer measures long-term memory. In patients with expressive aphasia, demands on speech production may be bypassed by having the patient select the test object from a set of objects. Such tests assess the ability to learn new material and evaluate the possibility of anterograde amnesia.

Tests of remote memory used to evaluate the possibility of retrograde amnesia (often referred to as long-term memory in standard neurological usage) require patients to recall past personal, geographical, or historical facts (e.g., the names of the last six presidents).

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